Provider Manual

overpayment recovery

Providers should submit claims consistent with national, state, and industry standards. To ensure adherence to these standards, Beacon Health Options relies on claims edits and investigative analysis process to identify claims that are not in accordance to national, state, and industry standards and therefore were paid in error. The claims edits and investigative analysis process includes, but is not limited to CMS’ National Correct Coding Initiative (NCCI). Examples of claim edits can include, but are not limited to, the following:

Procedure-to-procedure (PTP) edits that define pairs of HCPCS/CPT codes that should not be reported together.

Medically Unlikely Edits (MUE) units-of-service-edits. This component defines for each HCPCS/CPT code the number of units of service that is unlikely to be correct and therefore need to be supported by medical records.

Other Edits for Improperly Coded Claims-regulatory or level of care requirements for correct coding, including and not limited to:

Invalid procedure and/or diagnosis codes

Invalid code for place of service

Invalid or inappropriate modifier for a code

State-specific edits to support Medicaid requirements

Diagnosis codes that do not support the procedure

Add-on codes reported without a primary procedure code

Charges not supported by documentation based on review of medical records

Claims from suspected fraudulent activities for provider and members that warrant additional review and consideration

Services provided by a sanctioned provider or provider whose license has been revoked or restricted

Incorrect fee schedule applied

Duplicate claims in error

No authorization on file for a service that requires a prior authorization

Providers should routinely review claims and payments in an effort to assure that they code correctly and have not received any overpayments. Beacon will notify provider of overpayments by Beacon, clients and/or government agencies, and/or their respective designees. Overpayment include but are not limited to:

Claims paid in error

Claims allowed/paid greater than billed

Inpatient claim charges equal to the allowed amounts

Duplicate payments

Payments made for individual whose benefit coverage is or was terminated

Payments made for services in excess of applicable benefit limitations

Payments made in excess of amounts due in instance of their party liability and/or coordination of benefits

Claims submitted contrary to national and industry standards such as the CMS National Correct Coding Initiative (NCCI), procedure-to-procedure edits (PTP) and medical unlikely edits (MUE).